Qualitative evaluation of paediatric burn injury in Malawi: assessing opportunities for injury prevention

Introduction: The burden of burn injury in sub-Saharan Africa is high and children bare a disproportional share of the injury burden. Methods: This is a prospective qualitative study of paediatric burn survivors (age, ≤8 years) admitted to Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. Results: There were a total of 72 guardians interviewed for the purpose of the study. The most frequent mechanisms of burn injury were flames and scalds in 44.4% and 38.9%, respectively. Mothers were present at the time of the burn injury in only 23.6% of cases, while 22.2% of children were unmonitored at the time of injury. A total of 55.6% of burn injuries was cooking-related. Conclusion: Burn prevention strategies are necessary for addressing the high rates of burns for children in sub-Saharan Africa. The must be focused on mothers and caregivers burn education in the home, particularly as it relates to cooking and parental oversight

A legal-realist assessment of human rights, right to health and standards of healthcare in the Malawian prison system during COVID-19 state disaster measures.

Purpose: The first case of COVID-19 in the Malawi prison system was reported in July 2020. Human rights organisations raised concerns about the possibility of significant COVID-19 outbreaks and deaths in the prison system, due to the poor infrastructure, lack of health care and adequate COVID-19 mitigation measures, existing co-morbidities (tuberculosis, HIV, hepatitis C), malnutrition and poor health of many prisoners. Design/methodology/approach: We conducted a legal-realist assessment of the Malawian prison system response to COVID-19 during state disaster measures, with a specific focus on the right to health and standards of health care as mandated in international, African and domestic law. Findings: The Malawi prison system was relatively successful in preventing serious COVID-19 outbreaks in its prisons, despite the lack of resources and the ad hoc reactive approach adopted. Whilst the Malawi national COVID plan was aligned to international and regional protocols, the combination of infrastructural deficits (clinical staff, medical provisions) and poor conditions of detention (congestion, lack of ventilation, hygiene and sanitation) were conducive to poor health and the spread of communicable disease. The state of disaster declared by the Malawi government and visitation restrictions at prisons worsened prison conditions for those working and living there. Originality: In sub-Saharan Africa, there is limited capacity of prisons to adequately respond to COVID-19. This is the first legal-realist assessment of the Malawian prison system approach to tackling COVID-19, and it contributes to a growing evidence of human rights-based investigations into COVID19 responses in African prisons (Ethiopia, South Africa, Zimbabwe)

Judiciarisation of the mentally ill and/or mentally incapacitated in the Malawi criminal justice system: Gaps and flaws of human rights protection

Rates (where recorded) of mental illness, intellectual disabilities and co-morbidities are disproportionately high and rising among global prison populations. There is little data on the extent of mental illness and/or mental incapacity in prison populations in the Global South. Criminal justice systems are generally under-resourced, with a lack of adequate forensic monitoring, availability of specialist psychological and psychiatric expertise, and system coordination with mental health treatment and support services. Very little is known with regard to the judiciarisation of the mentally ill and/or mentally incapacitated in African criminal justice systems. In this Commentary we focus on Malawi, as a least developed country in sub-Saharan Africa. We present the international human rights framework pertinent to the judiciarisation of people with disability, the global discourse around disability-neutral doctrines and the contentiousness of the link between mental and legal capacity. We discuss challenges and procedural complexities in the Malawi criminal justice system as it relates to how people with mental illness and/or mental incapacity navigate the process and to what extent their basic human rights are upheld. Mental health legislation and policies to uphold the rights of the mentally ill and/or mentally incapacitated in the criminal justice system are underdeveloped (and under-resourced). There are backlogs in forensic assessments to determine competency to stand trial and criminal responsibility; inadequate availability of forensic beds; and insufficient coverage of community and prison based mental health services. Lengthy detention periods in overcrowded unsafe conditions are common, with little or no access to specialist medical care. We present medico-legal and clinical recommendations for enhanced human rights monitoring and protections cognisant of the various challenges in ensuring the implementation of human rights and of due process in Malawi. We encourage the government to consider formal diversion options via mental health courts and invest in the capacity of forensic specialists and hospitals to support court assessments and community care. Oversight mechanisms preventing human rights abuses of these very vulnerable individuals are crucial in all mental health settings in Malawi, not limited to police custody, remand detention facilities and prisons. Ratification of the Optional Protocol of the Convention against Torture is imperative

“Prison life can make you go crazy”: Insights into the situation for people with a mental illness in the Malawi prison system

Little is known with regard to due process and forensic assessment capacities in Africa, where over one million are deprived of their liberty on any given day. A rapid situation assessment explored multi-stakeholder perspectives regarding the situation of people with a mental illness in the Malawi prison system. In-depth interviews were conducted with 10 regional professional stakeholders, 18 former prisoners, and five prison staff from two maximum-security prisons. Reflexive thematic analysis yielded five themes; Occurrence of mental illness among people living in prison; Prison environment exacerbating harm and levels of mental illness; Security responses to the presence of psychiatric disorders; Availability and coverage of specialist psychiatric and psychological care; and Diversion, other non-custodial measures and continuity of care on release. Narratives highlight the substantial causal impact of the prison environment in amplifying existing and new mental illness, vulnerability and exploitation of people with a mental disorder. Malawi prisons are hampered by lack of specialist forensic capacity nationally; centralized mental health surveillance system; and insufficient skilled staff to conduct evidence-based screening and care. Security operations implement the use of pharmacological and physical restraint measures at times. Faith-based organizations play an important role in providing psychological and spiritual support. Release and reintegration require family involvement. A cross departmental intersectoral partnership response spanning government ministries, key civil society organisations, the Malawi Prison Inspectorate and Malawi Human Rights Commission is warranted. Recommendations include alleviation of prison congestion, prison staff capacity building and investment in forensic mental health services with adequate geographic coverage

A multi-stakeholder situation assessment of COVID-19 disease preparedness and mitigation measures in a large prison complex in Malawi.

Purpose: Prisons in the sub-Saharan African region face unprecedented challenges during the COVID19 pandemic. In Malawi, the first prison system case of COVID-19 was notified in July 2020. While, prison settings were included in the 2nd domestic COVID-19 response plan within the Law Enforcement cluster (National COVID-19 preparedness and response plan, July-December 2020), they were initially not included in the K157 billion (USD 210 million) COVID-19 fund. Design/methodology/approach: A multi-method situation assessment of the COVID-19 response and human rights assurance of prisoners and staff was conducted in a large prison complex in Malawi. Qualitative research underpinned by the Empirical Phenomenological Psychological (EPP) framework consisted of interviews with key informants such as prison health personnel, senior prison staff, penal and judicial policymakers, government and civil society organisations (n = 14) and focus group discussions with consenting male (n = 48) and female prisoners (n = 48), and prison wardens (n = 24). Prison site visits were supported by detailed observations based on the WHO Checklist for COVID-19 in prisons (n = 9). Data were collected and analysed thematically using the EPP stepwise approach and triangulated based on Bronfenbrenner’s model conceptualising COVID-19 as a multi-level event disrupting the prison eco-system. Findings: The results are presented as MICRO-MESO level individual and community experiences of incarceration during COVID-19 spanning several themes: Awareness raising and knowledge of COVID-19 in prisons; Prison congestion and the impossibility of social distancing; Lack of adequate ventilation, hygiene and sanitation and Provisions and correct use of personal protective equipment (PPE); MESO-MACRO level interplay between the prison community of prisoners and staff and judicial policy impacts; Medical system COVID-19 response, infrastructure and access to healthcare; COVID19 detection and quarantine measures and Prisoner access to the outside world. Originality: This unique situation assessment of the Malawian prison system response to mitigate COVID-19 illustrates the dynamics at the micro-level whereby prisoners rely on the State and have restricted agency in protecting themselves from disease. This is due to severe structural inadequacies based on low resource allocation to prisons leading to a compromised ability to prevent and treat disease; an infirm and congested infrastructure and bottlenecks in the judicial system fueling a continued influx of remand detainees leading to high over capacity. Multi-pronged interventions involving key stakeholders, with prison management and line Ministry as coordinators are warranted to optimise COVID-19 interventions and future disease outbreaks in the Malawian prison system

Moving beyond the politization of same sex sexuality and leveraging right to health to counter inter-personal sexual violence and HIV in Malawi’s prisons.

Sexual minority rights in contemporary Africa is a contentious issue, where in some countries, same-sexuality is portrayed by media and politicians as “un-African” and a “white disease” imported from the West. Samesex sexual activity is criminalised in 31 African countries. Political, legal and religious frameworks exacerbate homophobic attitudes, and related discrimination and hate crimes toward individuals who identify as lesbian, gay, bisexual or transgender (LGBT). We focus here on the rights of people in prison to protection from harm (same-sex sexual violence and sexually transmitted diseases), and who (in many African countries) are ignored in national HIV prevention programming. Prison conditions in Africa are harsh and congested, with inadequate basic needs provisions and this fuels exposure of the vulnerable to sexual violence and engagement in survival sex. HIV rates in prisons are also disproportionately higher than in the community. We present a socio-legal assessment on Malawi where same-sex sexual behaviours are criminalised. The assessment highlights how inmates’ exposure to sexual violence is invisible in political, legal, human rights and public health/HIV agendas in Malawi. Notwithstanding that the Malawi Penal Code and Prison Act prohibits same-sex sexual activity, there are enormous complications with victim disclosure, as claims of rape infer that sodomy has occurred, resulting in victim arrest. We focus here on tackling sexual violence and HIV, and advocate for broad based torture prevention initiatives in prisons to protect the vulnerable from inter-personal sexual violence, and consequent acquisition and onward transmission of HIV. The voices of people in prison in Malawi are regrettably still kept out of societal and public health discourses

‘Shamba’: Understanding and responding to the drivers and dynamics of same-sex sexual activity, sexual violence and HIV risk in the Malawi prison system.

Consensual same-sex relations and transgender expression are prohibited in Malawi. In-depth interviews (eight professionals, 30 former prisoners) were conducted to garner unique insights into the dynamics and complexities of prison conditions, human immunodeficiency virus (HIV) transmission, same-sex sexual activity and sexual violence. Reflexive thematic analysis yielded six themes: Covert same sex sexual activity behind the walls of the Malawi Prison System; Survival-based sexual transactions; Consensual and forced same-sex sexual activity; Sexual urges and crossing the homosexual Rubicon; Health consequences; and Inadequate and insufficient vocational development and rehabilitation.. The government is recommended to repeal its laws and improve standards of detention (safety, space, food), healthcare and provide trauma-informed rehabilitation/reintegration for all. Advocacy efforts are warranted to scale up the HIV comprehensive package

Summary of observed transmitted HIV drug resistance mutations (Mount Hagen, Western Highlands Province).

<p>Summary of observed transmitted HIV drug resistance mutations (Mount Hagen, Western Highlands Province).</p

Demographic characteristics of survey participants.

<p>Demographic characteristics of survey participants.</p